Proceeds from the sale will go to Dogwood Health Trust, a foundation created earlier this year. It will use earnings from investing sale proceeds, plus any remaining cash and investments owned by Mission after the health system's debts are satisfied, to fund programs intended to improve the health of Western North Carolina residents.

The actual agreement was not released Friday.

The Citizen Times asked both Mission and HCA for a copy of the agreement. Representatives of both said they would make no further information available Friday.

Mission made announcement of the agreement in a press release but declined to release more detail. Mission officials "do not have anything additional to share beyond what is contained in the press release," said Rowena Buffett Timms, senior vice president for government and community relations.

Mission's announcement says HCA has agreed to continue to operate key clinical services for at least five years and keep all of Mission's acute-care and rehabilitation hospitals open for 10 years. That does not include St. Joseph's Hospital in Asheville. Mission plans to consolidate many of the services now offered there into its "Mission" campus on the opposite side of Biltmore Avenue.

Mission said HCA has committed to $430 million over five years in capital expenditures. That includes completion of the Mission Hospital for Advanced Medicine now under construction on the main Mission campus, building a replacement hospital for Angel Medical Center in Franklin and building a new behavioral health hospital.

Plans for Angel had been announced previously but there had been little or no public mention of a new hospital for behavioral health before Friday. The announcement offers no details about it.

HCA and Mission will contribute $25 million each to create a $50 million "innovation fund" that Mission's announcement said will "invest in businesses providing innovations in health care delivery that benefit the people of western North Carolina."

Mission is a nonprofit that has operated in WNC for more than a century and employs 12,000 people. It operates hospitals in Asheville, Brevard, Franklin, Highlands, Marion and Spruce Pine plus numerous physician practices, a home health care agency and other health care facilities.

HCA is a for-profit company based in Nashville, Tennessee, that operates 178 hospitals in 20 U.S. states and in the United Kingdom.

Friday's announcement says Mission Health will continue to be managed locally. Nearly all Mission Health facilities and clinics will become part of HCA Healthcare while continuing to operate under the Mission brand, Mission said.

There have already been some discussions between Mission and the state Department of Justice over the department's review of the sale.

"The attorney general and his team are prepared to conduct a full legal review of this agreement and will do so once we have received all relevant information," said Laura Brewer, spokesman for Attorney General Josh Stein. "Because of the importance of this transaction, our office will prioritize diligence over speed. The attorney general is committed to making sure that the communities that built Mission Health are appropriately protected."

Some concerns about deal remain

People have been watching since March to see whether negotiations between Mission and HCA would result in a sale.

Friday's announcement got a mixed reception from Risa Larsen, one of the leaders of a group of people in Mitchell and Yancey counties who have been pressing for health services to remain at Blue Ridge Regional Hospital in Spruce Pine.

She said the group is "cautiously optimistic about the protections that are described in today’s press release about the sale of Mission Health system," especially those regarding keeping key health services and acute-care hospitals like Blue Ridge in place.

But, Larsen added, "We are cautious because we haven’t seen the details of the agreement. For instance, what are the specific key clinical services that will be maintained?"

She said she is still concerned by how Dogwood Health Trust is to be governed, saying many of its board members have or have had close ties to Mission, raising concerns about possible conflicts of interest.

Asheville Mayor Esther Manheimer said she feels confident services Mission offers now will continue to be available to residents of Asheville and Buncombe County if the sale goes through.

"From what I am hearing ... the medical care will continue to be excellent," she said, although care in rural areas may be more at risk over the long term.

But, somewhat like Larsen, she said more needs to be done to ensure there is public input into decisions about the focus of Dogwood Health Trust.

"It could be an amazing opportunity, but (Dogwood) leadership needs to work with the community to make the most of this situation," Manheimer said.

Long-term financial worries

Mission officials have said they began looking at a sale because of long-term financial pressure created by the high proportion of its patients whose care is covered by Medicare or Medicaid, government programs that Mission says do not pay the full cost of care.

The system also engaged in a high-profile battle last year with the state's dominant health insurance company, Blue Cross Blue Shield of North Carolina, over contract terms. The two sides were able to come to an agreement only after a period in which Mission was "out of network" for holders of Blue Cross insurance.

Mission's financial statement for the fiscal year ended last September said it was still profitable, but health system officials said they faced the prospect of cuts in services in the years ahead in order to stay in the black. They say HCA will be able to operate back office services like billing and purchasing more efficiently.

“From the very beginning, Mission Health’s board worked diligently and continually to ensure that the very best path was selected for the people of western North Carolina and to make certain that our community has access to high quality, effective and compassionate care for generations to come,” said Mission Health Board Chair Dr. John Ball.

“After completing due diligence and finalizing definitive agreements that have significant protections for our rural communities, we are convinced that HCA Healthcare is the right and best choice for western North Carolina and Mission’s team members, providers and patients," Ball said.

He said the boards of each Mission unit voted unanimously to approve the deal.

“Mission Health has an impressive, more than 130-year tradition of caring for communities throughout western North Carolina and we are delighted to have finalized our agreements so that we can help continue their legacy,” said Milton Johnson, HCA Healthcare’s chairman and CEO.

“As a healthcare provider founded by physicians 50 years ago ourselves, we share Mission Health’s focus on excellence and we look forward to investing in western North Carolina to improve the health of the region," Johnson said.

State law says the Department of Justice can take up to 60 days to review a proposed sale such as Mission's after it has received all of the information it needs.

If the department objects to the sale, it would have to file a lawsuit to block it and a judge or jury would decide whether the sale would go through.

The announcement by Mission and HCA in March that they had signed a letter of intent to negotiate a sale has prompted both praise and fears in the months since.

Some have said the move appears to be necessary to ensure Mission's viability over the long term and that Dogwood Health Trust could make a significant contribution to efforts to attack social problems that contribute to health issues in the region.

Others have worried about the effects on the quality of care and availability of services of a sale to a for-profit company, with those served by Mission's rural hospitals particularly concerned about their future under HCA.